Treatment Planning Processes in Dental Schools Charles R. Hook, D.M.D.; Robert W. Comer, D.M.D.; Robert M. Trombly, D.D.S., J.D.; John W. Guinn III, D.D.S.; Michael K. Shrout, D.M.D. Abstract: Treatment planning is a critical aspect of clinical education in the dental school curriculum. It is surprising, therefore, that so little attention has been given to this subject in the dental literature. The importance of treatment planning is reinforced in the standards and the tests that clearly present methods and necessity for treatment planning. However, there is minimal evidence about how these treatment planning courses have been evaluated, how they were incorporated into the curriculum, or how they have been integrated into treatment planning in the academic clinical setting. The purpose of this study was to survey and profile current treatment planning processes in U.S. dental schools. A questionnaire consisting of twenty-nine items relating to treatment plan preparation, process, and outcomes was mailed to fifty-four U.S. dental schools. The primary topics included patient assignments, treatment planning, plan sequencing, plan presentation, informed consent, and plan modifications. Forty-seven of the fifty-four U.S. dental schools (87 percent) completed and returned the surveys. Profiling the treatment planning process in dental schools reveals many similarities. Typically, the schools screen patients prior to assignment to students and expect the student diagnostician to complete the planning process as well as comprehensive care. The patient’s welfare is the primary determinant of the content of the plan in 92 percent of U.S. dental schools. Secondly, though current accreditation standards are concentrated on competencies, the treatment plans are influenced by quantitative requirements. Third, the plan is usually completed during the second patient visit after screening. Fourth, the approaches vary among the schools when a multidisciplinary or complex treatment plan is appropriate. Some depend on a panel of experts, whereas others do not have interactive planning with specialists. A significant number of schools decentralize treatment planning and delegate part of the plan to disciplines or group practice leaders. Fifth, the treatment plans and treatment risks are presented in accordance with the intent of the accreditation guidelines; however, fewer than half the schools explain the risk of procedures to patients at the time of plan presentation. Finally, plans change frequently, but the modifications are generally considered to be minor. Dr. Hook is Associate Dean for Clinical Affairs, Medical University of South Carolina College of Dental Medicine; Dr. Comer is Associate Dean for Patient Services, School of Dentistry, Medical College of Georgia; Dr. Trombly is Associate Dean for Clinical Affairs, University of Colorado, School of Dentistry; Dr. Guinn is Associate Professor in the Department of Oral Diagnosis, School of Dentistry, Medical College of Georgia; Dr. Shrout is Professor in the Department of Oral Diagnosis, School of Dentistry, Medical College of Georgia. Direct correspondence and requests for reprints to Dr. Robert W. Comer, Associate Dean for Patient Services, School of Dentistry, Medical College of Georgia, Augusta, GA 30912-1241; 706-721-6276 fax; [email protected]. Key words: patient assignment, treatment plan development, treatment plan sequencing, treatment plan presentation, treatment plan execution, treatment plan modification Submitted for publication 8/20/01; accepted 10/22/01

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reatment planning is the process of formulating a rational sequence of treatment steps designed to eliminate disease and restore efficient, comfortable, esthetic masticatory function to a patient.1,2 The plan guides succeeding patient visits and is a critical aspect of clinical dentistry and clinical education in the dental school curriculum.3 Despite its importance, however, treatment planning has received little attention in the dental literature. A solitary survey of seventy American and Canadian dental schools conducted in 1984 showed that most dental schools offer preclinical treatment planning information and also develop clinical treatment plans. These may vary from identification of general treatment areas to comprehensive, sequential treatment plans with alternative treatment options.3 The sur-

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vey also revealed that in the mid-1980s there was generally no definite distinction between oral diagnosis and treatment planning. Finally, according to this report, there were no curricular guidelines devoted to the principles of dental treatment planning. This is alarming because treatment planning is considered by dental educators and accreditors to be an essential element both for the students’ education and the provision of patient services.4 Two sources of information reinforce the importance of treatment planning. Accreditation standards require schools to demonstrate competency in comprehensive planning 5; and secondly, many of the texts clearly present the methods for and the necessity of treatment planning.4,6-8

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Purpose This study was conducted to survey current treatment planning processes in U.S. dental schools. Specifically, the purpose of this study was to profile treatment planning processes to include: • The patient assignment process, • Developing the plan, • Sequencing guidelines, • Styles of plan presentation and informed consent to treatment, and • Methods for modifying existing plans.

Methodology A questionnaire consisting of twenty-nine items relating to treatment plan preparation, process, and outcomes was mailed to fifty-four U.S. dental schools. The survey was directed to the clinical administrator in each school. This person was requested to forward the questionnaire to the faculty member most familiar with the details of treatment planning in the school. Follow-up surveys were distributed to nonrespondents approximately four weeks later. The responses were then consolidated into a profile of the “typical” approach of dental schools to patient assignment process; the treatment plan development; sequencing of procedures; modification of the initial plan; and, finally, the treatment plan execution. The questionnaire was previewed and refined in three schools; however, pilot surveys were not prepared for data testing. Some of the items on the survey were presented as lists from which the respondents could select multiple responses. Other items were yes/no questions followed by choices that indicated anticipated reasons and constraints. Finally, some survey items were presented on a 5-point Likert scale. When appropriate, the questions and lists included an openended “other” option for additional responses or explanations. Questions were designed to gather data that would profile common practices among the schools. The primary topics included the following. Patient Assignments. The first topic explored was the identification of the screening methods and practices prior to or subsequent to the assignment to a primary provider. Screening is generally considered a cursory examination for the purpose of classifying or categorizing the general needs of patients.

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Treatment Planning. The initial survey questions were designed to identify the processes and methods utilized in dental schools to generate and then to evaluate the appropriateness of treatment plans. The responsibility and processes for developing comprehensive treatment plans were presented next. Plan Sequencing. The next set of questions was to determine how much time is required to generate a plan and who defines the treatment sequence. The purpose was to identify the responsible person and to examine variations for the complex multidisciplinary cases. Plan Presentation and Informed Consent. After a plan is developed and approved by faculty, there are various methods to present the plan to the patient and to obtain informed consent. These presentation methods, including visual aids such as brochures, films, and illustrations, were included in several questions. Modifying a Plan. Finally, once a plan is approved, questions were designed to identify who is authorized to modify a plan, the frequency of modifications, the scope of change, and the process for change.

Results Forty-seven of the fifty-four U.S. dental schools (87 percent) completed and returned the surveys. Presented below are generalizations as to the “typical” approach in processing patients from initial screening through finalization of an approved plan; case presentation to the patients of the findings and recommendations for treatment; obtaining informed consent; and accommodating modifications to the initial plan. The results were tabulated and the responses were ranked by frequency to profile the most and least used treatment planning processes.

Patient Assignment Several items in the survey were included to identify preliminary activities such as the assessment of patient needs, the assignment process, and the frequency and length of visits. Respondents were consistent with the initial or cursory evaluations. Ninetyone percent (forty-three respondents) of the schools screen prospective patients prior to their assignment. According to a recent study, approximately three-

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fourths of U.S. dental schools reported that either clinical affairs or the oral diagnosis departments were responsible for patient screening.9 Whereas 57 percent of schools involved students in the process, only one school reported that students were responsible for screening.9 Even though patient screening is a typical activity, there is slightly more variation in the screening/assignment process. About one third of the schools (fourteen) directly assign the patients at the initial screening appointment. Most schools, however, assign the patients after the screening appointment (thirty, or 64 percent). Seventy-nine percent (thirty-seven schools) assign the patients to students, and 13 percent (six) assign patient care responsibility to others such as patient care coordinators (six, or 13 percent). After assignment, the respondents indicated their preference was to have treatment provided by the person who developed the plan. They differed on the importance of continuity in having the preparer of the plan as the sole provider of all services. Most respondents (twenty-eight, or 60 percent) indicated that this aspect of continuity of planning and care was advisable; 19 percent (nine), practical; and 17 percent (eight) essential; while 13 percent (six) indicated that it is not important.

Developing the Plan In most instances the student assigned the responsibility for comprehensive case management is also responsible for developing the initial treatment plan (thirty-four, or 72 percent). Alternatively, students under faculty supervision in a treatment planning service develop the initial treatment plan (twelve, or 26 percent). These initial or comprehensive plans generally precede routine treatment. Most schools (thirty-eight, or 81 percent) require a comprehensive plan before nonemergency treatment begins. A majority of respondents (forty-three, or 91 percent) replied that the recommended plans provided a complete diagnosis and treatment plan to address all problems. Optimal patient care frequently requires input from several specialists and coordination among the dental disciplines. During the planning process, some institutions assemble a group of consulting specialists to examine the patient and collaborate on a recommended treatment plan. This group is typically referred to as a Treatment Planning Board. In many

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of the schools (twenty-one, or 45 percent), a Treatment Planning Board meets to develop a coordinated treatment plan. In an almost equal number of schools (nineteen, or 40 percent), the planning does not involve a group or Treatment Planning Board approach. Following the appropriate consultations and development of a treatment plan, the final approval of the plan content is the responsibility of faculty members in a treatment planning section or department (twenty-two, or 47 percent). In other schools (sixteen, or 34 percent), generalists serving as mentors or coordinators for a group of students assume the responsibility for final plan approval. They are responsible for all patients assigned to the students within the attending dentist’s group or team. The respondents indicated the factors that tend to influence the composition of a treatment plan. These are outlined in Table 1. Respondents stated the most significant influence on the proposed treatment plan is the patient’s disease status. Their responses indicate that the least influential factor is the student’s need for requirements or material for competency exams. Even though comprehensive care is espoused as a preferred approach, 72 percent (thirty-four) of the schools indicated they continue to have specific requirements in most disciplines. Furthermore, 47 percent (twenty-two) of the schools stated that the faculty at large would not accept a comprehensive care system with no unit requirements. Forty-three percent (twenty schools) accepted the concept of comprehensive care, while two preferred both, two did not respond, and one did not know. Several factors influenced the respondents’ opinions related to the concept of presenting a comprehensive care environment rather than a requirement driven system. These responses are outlined in Table 2. Totals do not equal 100 percent because multiple responses were allowed.

Plan Sequencing Generally, the plan for the patient’s treatment is completed on the second patient visit (twenty-eight, or 60 percent) following a screening appointment. Approximately one-third completed a plan during the first patient visit (fourteen, or 30 percent). The remaining schools finalized the plan during the third visit after the initial screening appointment (eleven, or 23 percent).

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Table 1. Factors that influence treatment plan content Degree of Importance

Factors Patients’ disease status Patients’ request Patients’ ability to pay Faculty preference Skill of student Student requirements Competency exams

Strongly Agree 5

4

3

42 24 15 4 4 3 2

3 21 18 31 12 8 7

1 0 5 5 25 26 30

2

Strongly Disagree 1

# Responding

Average

0 0 5 3 2 6 4

0 0 2 3 1 3 3

46 45 45 46 44 46 46

4.89 4.53 3.87 3.65 3.36 3.04 3.02

Table 2. Presentation of a comprehensive care environment

Table 3. Methods and materials used to present treatment plans

rather than a requirement-driven system is . . . Frequency %

Method

Preferable Appropriate Realistic Effective Expensive Economical Unrealistic

34 24 22 19 3 1 2

72% 51% 47% 40% 6% 2% 4%

In most instances, the treatment plan was sequenced by the students (twenty-seven, or 57 percent). The sequence specified both the phases of intended treatment (twenty-six, or 55 percent) and/or the exact order that the procedures will be addressed (twenty-six, or 55 percent). One school did not sequence treatment plans, and three did not prescribe a specific sequence of treatment procedures. Nine schools did not respond to the question. Multiple responses were provided by respondents.

Plan Presentation and Informed Consent Typically, a complete diagnosis and the recommended plan were presented to address all the patient’s dental needs and/or desires (forty-three, or 91 percent). According to 55 percent (twenty-six) of the schools, all patients were offered comprehensive care, which was generally defined as treatment for all identified problems (twenty-four schools, or 51 percent). Treatment plans were customarily presented to the patient using visual aids to illustrate or demonstrate procedures and techniques (twenty-seven schools, or 57 percent). The supporting information and visual aids presented to the patients most often

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Frequency of Response # Schools Reporting % of Schools

Written Plan Discussion No Answer Written Narrative ADA Videos Risks of Treatment Photographs Optional Plans Commercial Videos Locally Produced Videos Graphs Expected Outcome

20 18 16 14 13 12 11 9 9 8 8 2

43% 38% 34% 30% 28% 26% 23% 19% 19% 17% 17% 4%

included a written plan (twenty, or 43 percent), a discussion of the treatment options (eighteen, 38 percent), and a narrative explanation (fourteen, 30 percent). The frequency distribution of the visual aids such as videos, photographs, and handouts is presented in Table 3. Multiple responses were accepted. The treatment plans are typically compiled on a computer (thirty-one, or 66 percent) and/or handwritten in the patient record (twenty-eight, or 60 percent). Informed consent is generally included in the planning process. This consent includes the patient’s signed approval of the proposed treatment plan for 83 percent (thirty-nine) of the schools. The concomitant discussion with patients to explain the risk of individual treatment procedures was included in the planning process by only 43 percent (twenty) of the respondents. Some schools report that the individual departments present risk assessments and specific informed consent for specific procedures. Other components of informed consent mentioned infrequently included discussion of financial alternatives, general and anesthetic risks, and risk/benefits correlated with the cost of alternatives.

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Table 4. Reasons for favoring comprehensive care or requirements

Reason

Reason for Comprehensive Care # of Schools % of Schools

Respondent’s Preference Appropriate Realistic Effectiveness

34 24 22 19

72% 51% 47% 40%

Comprehensive Plan Execution Most respondents believe the concept of presenting a comprehensive care environment rather than a requirement-driven system of education is preferable (thirty-four schools, or 72 percent), appropriate (twenty-four, or 51 percent), realistic (twenty-two, or 47 percent), and effective (nineteen, 40 percent). However, as mentioned previously, faculties at large continue to insist on unit requirements with students having specific requirements in most treatment disciplines (thirty-four, or 72 percent). The reasons stated for maintaining a requirement system were tradition (twenty, or 43 percent), appropriateness (fifteen, or 32 percent), necessity (ten, or 21 percent), or administrative preference (seven, or 15 percent). Multiple responses were acceptable. The differences stated in preferences of comprehensive care systems and requirement systems are presented in Table 4.

Plan Modification Respondents were asked to indicate how frequently treatment plans may change during the course of treatment and who is authorized to change the plans. The frequencies of change are presented in Table 5. Minor modifications were specified as those that usually involved changes such as extending an MO amalgam to an MOD. Moderate changes included several additions or deletions of several procedures. Modifications in the treatment plan are usually authorized by the attending faculty (thirty-four schools, or 72 percent) and/or by the clinical director (seventeen, or 36 percent). In the predoctoral teaching program, the time for completion of a treatment plan was cited as appropriate (eleven schools, or 23 percent) or understandably extended (twenty-six, or 55 percent). The length of each patient visit is regarded either as appropriate (twenty-six, or 55 percent) or too long (twenty-one, or 45 percent). No one indicated that the patient visits were too short.

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Reason for Requirements # of Schools % of Schools

Reason

Respondent’s Preference Appropriateness Tradition Necessity

7 15 20 10

15% 32% 43% 21%

Discussion Profiling the treatment planning process in dental schools reveals many similarities. Typically, the schools screen patients prior to assignment to students and expect the student diagnostician to complete the planning process as well as comprehensive care. The outcome of screening is to assess patients and identify those whose needs correspond to the educational and service missions. In the general context, this information identifies patients whose needs are within the scope of services provided within the predoctoral program and within the range of the students’ ability. As a result, dental faculty are able to protect the patients by ensuring that beginning student dentists are not expected to address complex medical and dental problems beyond their ability and knowledge. Furthermore, the information from screening provides a categorization of patient needs to provide students with balanced educational experiences in the development of competence.9 The diagnostic process does not stop with oral diagnosis, but of necessity includes the ultimate optimally planned and sequenced treatment for each patient. The comprehensive plan addresses all problems and is most strongly influenced by patient needs and requests rather than the students’ or curricular expectations to fulfill quantitative guidelines. ReTable 5. Treatment plan modifications Frequency of Change # of Schools Frequently Seldom Never

37 10 0

Extent of Changes Are Usually # of Schools Minor Minor to Moderate Moderate Major No Response

22 6 16 1 2

% of Schools 79% 21% 0% % of Schools 47% 13% 34% 2% 4%

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spondents indicated that the patient’s welfare (needs and desires) receives overriding emphasis in 92 percent of U.S. dental schools. The practice of assigning patients to students rather than to licensed dentists may undergo scrutiny in the future. It is clearly acknowledged that attending faculty are responsible for patient care. They assess the quality of care, and indeed the procedures are performed either by or with a student under the umbrella of the licensed dentists present during care. However, the quality from the perspective of continuity and timeliness of care may be inappropriately delegated and managed by students. One may assume that each school has mechanisms to monitor the progress of patient care; but assigning the responsibility to specific licensed dentists may be considered more appropriate. Even though current accreditation standards emphasize competency-based assessment, an undercurrent of the influence of the quantitative requirement-driven system may still exist. Specifically, the respondents indicated that while they preferred the comprehensive care environment, they also reported that a significant number of faculty would not abandon requirements. Interestingly, 72 percent of the respondents reported that requirement-driven systems still exist in most disciplines within the institution. Presumably a greater number of schools relied on requirement systems in the past. It is also assumed that some systems currently depend on requirements as qualifiers for determination of competency. And it may be concluded that the transition is incomplete from traditional requirement-driven systems to comprehensive care systems that emphasize competency assessments of clinical educational outcomes as the primary measure of qualification for graduation. Ostensibly, current accreditation standards will encourage the pendulum to swing from requirementto competency-based systems. However, comparative data and benchmarks are not available in the literature. The data does not reveal how schools ensure that patients continue to receive comprehensive care as their student dentists complete their requirements. Therefore, if the final treatment for a patient is beyond the procedures required by the assigned student, the information available does not define how schools ensure that patient needs are resolved. To further complicate this process in the educational arena, the need for adequate clinical experiences, which are necessary to train the student, must be entered into the equation. The 1995 Institute of Medicine report, Dental Education at the Crossroads,

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states, “A procedure-driven learning process does not necessarily translate into efficient, high quality patient care.” It was further noted that “graduation requirements and evaluation procedures are a potential threat to quality of care.”10 Even though our survey showed most educators believe that a requirement-driven system is less desirable than comprehensive patient care, the majority of schools still enforce clinical requirements. A second aspect of treatment planning is plan development. This study reveals many similarities in the process. In order for care to be provided in an efficient, timely, organized manner, there needs to be an orderly phased and appropriately sequenced plan of treatment. The plan is usually completed during the second patient visit after screening and addresses all problems, the sequencing of steps in common, and the clustering of procedures into phases or treatment (prevention, disease control, emergency, reconstruction, etc.). It may be noteworthy that a third of the schools make direct assignments at screening, possibly eliminating one patient visit. Thirteen percent (six) of the schools assign patient management responsibility to a patient care coordinator, whereas nearly 80 percent of schools assign patients directly to students. The approaches vary among the schools when a multidisciplinary or complex treatment plan is appropriate. Approximately an equal number provide a panel of experts or a Treatment Planning Board (45 percent), whereas 40 percent do not have interactive planning among specialists. It is noted that a significant number of schools decentralize treatment planning and delegate part of the plan to disciplines or group practice leaders. Regardless of the use of a Treatment Planning Board, a panel of specialists, or an individual faculty number, the diagnosis and treatment planning for the complex cases may present an excellent opportunity for competency assessment in the transition from a requirements-driven system to a competency-based system. It is both ethically and legally necessary that patients be provided the examination results and recommended plan of care so that they can clearly comprehend their orofacial status. The accreditation standards are prescriptive on these aspects of patient rights.5 Following appropriate presentation of all findings and recommendations, the patient must acknowledge his or her understanding and desire to proceed, thereby indicating informed consent. The treatment plans and risks are presented in accordance with the

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intent of the accreditation guidelines (Standard 5).5 In accordance with patient rights, the plans and scope of services are presented. Surprisingly, however, fewer than half the schools discuss with the patient the risk of each procedure at the time of plan presentation. Most clinicians and dental students make a conscientious effort to develop optimal treatment plans to recommend to their patents. However, the practicing clinician/dental student and his or her patient should be flexible and anticipate that the treatment plan will more than likely change during the course of treatment. The initial treatment plan may require modifications for reasons such as changes in the prognosis as interim treatment outcomes are evaluated; changes in the patient’s desires, financial status, and systemic health; or possibly a combination of these factors. In the dental school environment, changes to initial treatment plans do occur frequently, but are usually minor to moderate in nature, with major changes being the exception. (See Table 5.)

Conclusion Within the predoctoral training environment of U.S. dental schools today, there are interesting variations in the treatment planning processes being followed. This study was conducted to identify and examine methods used in these schools to develop patient treatment plans. Evaluation of the results indicates that while many schools utilize similar methods, there are also stark differences in approach to treatment plan development, presentation, and execution. It appears that there is no consistent format being followed in the teaching and development of treatment plans within dental school curricula. The

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results of this survey indicate a need for further studies addressing the dental treatment planning process practiced in U.S. dental schools. Ultimately, further findings and recommendations might lead to a dental treatment planning model or protocol that educators could follow to best prepare developing dental students to competently and consistently undertake the most important subject of planning dental treatment.

REFERENCES 1. Moskona D, Kaplan I, Leibovich P, Notzer N, Begleiter A. A three-year programme in oral diagnosis and treatment planning: a model using an interdisciplinary teaching team. Eur J Dent Educ 1999;3:27-30. 2. Wood NK, Byrne G. Treatment planning in dentistry. In: Hardin J, ed. Clinical dentistry. Philadelphia: Lippincott, 1991. 3. Kennon S, Sleamaker TF, Farman AG. Treatment planning instruction in North American dental schools, 198485. J Dent Educ 1985;49(10):702-6. 4. Barsh LI. Dental treatment planning for the adult patient. Philadelphia: W.B. Saunders Co., 1981. 5. Commission on Dental Accreditation. Accreditation standards for dental education programs. Chicago: American Dental Association, 1998. 6. Coleman GC, Nelson JF. Principles of oral diagnosis. St. Louis: Mosby Yearbook, 1993. 7. Hall WB, Roberts WE, LaBarre EE. Decision making in dental treatment planning. St. Louis: Mosby, 1994. 8. Bricker SL, Langlais RP, Miller CS. Oral diagnosis, oral medicine, and treatment planning, 2nd ed. Philadelphia: Lea & Febiger, 1994. 9. Hagan BA, Comer RW, Laswell HR, Konzelman JL, Herman WW. Patient support services. J Dent Educ 2000;64(1):9-16. 10. Field MJ, ed. Dental education at the crossroads: change and challenge. Washington, DC: National Academy Press, 1995:ch.6.

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